Screen All Adults for Hepatitis B, CDC Says

All adults should be tested for a hepatitis B virus (HBV) infection at least once in their lifetime, and a wider range should get periodic retesting, according to new CDC recommendations.

The report recommended moving from a risk-based approach to a universal approach in order to increase awareness of infection and reduce chronic disease and premature death.

"Overall, risk-based testing has been insufficient to identify persons with HBV infection in the United States and has been a barrier to appropriately screening populations with a disproportionate prevalence of disease," Erin E. Conners, PhD, of the CDC's National Center for HIV, Viral Hepatitis, STD, and TB Prevention, and colleagues wrote in Morbidity and Mortality Weekly Report.

Screening should be triple-panel, including HBV surface antigen (HBsAg), antibodies to them (anti-HBs), and total hepatitis B core antibody (anti-HBc), they wrote.

"A one-time HBV screening of adults would be complementary to the 2022 Advisory Committee on Immunization Practices (ACIP) recommendation to vaccinate all adults aged 19-59 years for HBV infection because screening establishes any history of infection, and vaccination protects from future infection and need for additional testing," Conners and colleagues added.

Currently, there are an estimated 580,000 to 2.4 million people living with HBV infection in the U.S., according to the CDC report, and two-thirds of those might be unaware of their infection. An estimated 1.89 million people are chronically infected with HBV, which can lead to substantial morbidity and mortality. Of note, chronic HBV disproportionately affects people born abroad (about three-fourths of U.S. cases).

People chronically infected with HBV infection are at increased risk for liver cancer and cirrhosis and are 70-85% more likely to die prematurely than the general population.

"Although treatment is not considered curative, antiviral treatment, monitoring, and liver cancer surveillance can reduce morbidity and mortality," said Conners and colleagues.

Before 2008, screening recommendations were risk-based and included pregnant women, infants born to infected mothers or born with HIV, household contacts and partners of infected persons, and people exposed such as by needlestick injury or sexual assault. In a 2008 update, screening recommendations were expanded to people born in places with high HBV prevalence, people who had behavioral exposures to HBV (men who have sex with men and injection drug users), those receiving cytotoxic or immunosuppressive therapy, and people with liver disease with an unknown etiology.

The current screening guidelines widened the recommendations further to recommend that "anyone who requests HBV testing should receive it, regardless of disclosure of risk, because many persons might be reluctant to disclose stigmatizing risks."

In addition, the CDC now recommends that testing in pregnancy occur in the first trimester of each pregnancy and "regardless of vaccination status or history of testing." If a pregnant person has been recently screened and has not been exposed to an HBV risk since screening, only HBsAg screening is recommended.

In parallel, the current report recommended continual periodic testing for those at higher risk, regardless of age, as long as the risk exposure is ongoing. It further expanded the definition of high-risk individuals to include people who are incarcerated or formerly incarcerated in a prison or other detention setting, people with a history of sexually transmitted infections or multiple sex partners, and those who have had hepatitis C.

The CDC noted that the rate of reported acute HBV infection in 2019 was 1.0 per 100,000 population in the U.S., whereas the rate has remained at 0.1 cases or below in those up to 19 years of age because of routine vaccination.

Adults have "suboptimal" vaccine uptake, Conners' group wrote, though a recommendation for HBV vaccination now appears in the 2023 adult immunization schedule.

Once an adult has had blood taken for HBV serologic testing, those who have not completed a vaccine series should be offered vaccination per ACIP recommendations at the same visit or at an associated provider visit, the report said. "Blood collection before vaccination is recommended because transient HBsAg positivity has been reported for up to 18 days after vaccination."

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